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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> �_VEHIISLEIN -61R.MATION:. <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> .NEIiICLEDWA NEA INFORMATION <br /> x' Name: � � - - - -1 - - <br /> Address of Owner: 3913 do Qkc—.' CA q5ZLQ <br /> Street Address city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office may result in pe ittion and penalties. <br /> Si IFe' hicle Operator Date <br /> -COMMISSARY INFORMATION - <br /> Business Name: L� ` <br /> Owner Name: A 19 A <br /> Site Address: G` r I � / f <br /> Street Address city <br /> Phone: ( 04' .e <br /> I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> ❑ Liquid&solid waste disposal ❑ Utensil washing sink St re frozen food ❑ Vehicle wash facilities <br /> (2 or 3 compartments) <br /> F] Preparation of food ❑ Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> ❑ Store dry food/suppli ❑ Provide potable water Overnight parking Sa Adequate electrical outlets <br /> Signature of sa Owner/Operator Date <br /> `HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />